HEALTH CARE 

WORKFORCE

HRSA Action Needed 

to Publish Timely 

National Supply and 

Demand Projections

Report to Congressional Requesters

September 2013

GAO-13-806

United States Government Accountability Office
United States Government Accountability Office

Highlights of GAO-13-806, a report to 

congressional requesters

September 2013

HEALTH CARE WORKFORCE 

HRSA Action Needed to Publish Timely National 

Supply and Demand Projections

Why GAO Did This Study

For over a decade, government, 

academic, and health professional 

organizations have projected national 

shortages of health care professionals, 

which could adversely affect patients’ 

access to care. However, there is little 

consensus about the nature and extent 

of future shortages, partly because of 

the complexity of creating projections 

and uncertainty about future health 

care system changes. Up-to-date 

workforce estimates are essential 

given the significant federal investment 

in health care training programs. Within 

HHS, HRSA is responsible for 

monitoring health care workforce 

adequacy; to do this, HRSA conducts 

and contracts for workforce studies. 

GAO was asked to provide information 

about health care workforce 

projections. This report examines the 

actions HRSA has taken to project the 

future supply of and demand for 

physicians, physician assistants, and 

advanced practice registered nurses 

since publishing its 2008 report. GAO 

reviewed HRSA’s contract 

documentation, select delivered 

products, and timeline goals for 

publication. GAO also interviewed 

HRSA officials, workforce researchers, 

and provider organizations.

What GAO Recommends

GAO recommends that the 

Administrator of HRSA expedite the 

review and publication of HRSA’s 

report on national projections for the 

primary care workforce, create 

standard written procedures for report 

review, and develop tools to monitor 

report review to ensure timeline goals

for publication are met. HHS agreed 

with GAO’s recommendations and 

provided technical comments.

What GAO Found

Since 2008, the Health Resources and Services Administration (HRSA) within 

the Department of Health and Human Services (HHS) has awarded five contracts 

to research organizations to update national workforce projections, but HRSA 

has failed to publish any new reports containing projections. As a result, the most 

recent projections from HRSA available to Congress and others to inform health 

care workforce policy decisions are from the agency’s 2008 report, which is 

based on data that are more than a decade old. While HRSA created a timeline 

for publishing new workforce projection reports in 2012, the agency missed its 

goal to publish a clinician specialty report by December 2012 projecting the 

supply of and demand for health care professionals through 2025. HRSA officials 

attributed the delay in publishing this report to data challenges and modeling 

limitations. HRSA has also revised its timeline to postpone publication of two 

other health care workforce reports, as shown in the table below. HRSA officials 

said that the agency does not have standard written procedures for preparing a 

report for publication after final reports are delivered from contractors, which may 

impede its ability to accurately predict how long products will take to review and 

monitor their progress through the review process.

Health Resources and Services Administration’s (HRSA) Original and Revised Timelines for 

Publishing Updated Workforce Supply and Demand Projections

Report Description

Original goal 

for publication

Revised goal 

for publication

Primary care Projects supply of and demand for 

the primary care workforce to 2020.

No goal date Fall 2013

Clinician specialty Projects supply of and demand for 

physicians, physician assistants, and 

certain advanced practice registered 

nursesa (APRN) to 2025.

December 2012 Summer 2014

Nursing workforce Projects supply of and demand for 

nurses, including APRNs, to 2030.

September 2013 Fall 2014

Cross-occupations Projects supply of and demand for 

more than 20 health professions to 

2030.

2013 2014

Source: GAO review of HRSA information. 

a

Includes nurse practitioners, certified registered nurse anesthetists, and certified nurse-midwives. 

Clinical nurse specialists are not included. 

View GAO-13-806. For more information, 

contact Kathleen M. King at (202) 512-7114 or 

kingk@gao.gov. 
Page i GAO-13-806 Health Care Workforce Projections

Letter 1 

Background 4

HRSA Has Taken Some Actions to Update National Projections, 

but Has Failed to Publish New Reports Since 2008 12

Conclusions 16

Recommendations 17

Agency Comments 18

Appendix I Comments from the Department of Health and Human 

Services 20

Appendix II GAO Contact and Staff Acknowledgments 23

Tables

Table 1: Selected Program Areas Addressed by the Patient 

Protection and Affordable Care Act (PPACA) and Their 

Potential Health Care Workforce Effects 10

Table 2: Summary of the Health Resources and Services 

Administration’s (HRSA) Contracts with Research 

Organizations Since 2008 to Create Health Care Workforce 

Projections 13

Table 3: Health Resources and Services Administration’s (HRSA) 

National Center for Health Workforce Analysis Original 

and Revised Timelines for Publishing Updated Workforce 

Supply and Demand Projections 14

Figure

Figure 1: Process for Determining Physician Requirements in the 

Health Resources and Services Administration’s (HRSA) 

2008 Report Based on Its Physician Requirements Model 8

Contents 
Page ii GAO-13-806 Health Care Workforce Projections

Abbreviations

AAMC Association of American Medical Colleges

ACO accountable care organization

APRN advanced practice registered nurse

BHPr Bureau of Health Professions

FTE full-time equivalent

HHS Department of Health and Human Services

HRSA Health Resources and Services Administration

NCHWA National Center for Health Workforce Analysis

PCMH patient-centered medical home

PPACA Patient Protection and Affordable Care Act

PRM Physician Requirements Model

PSM Physician Supply Model

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Page 1 GAO-13-806 Health Care Workforce Projections

441 G St. N.W.

Washington, DC 20548

September 30, 2013

The Honorable Tom Coburn

Ranking Member

Committee on Homeland Security and Governmental Affairs

United States Senate

The Honorable Richard Burr

Ranking Member

Subcommittee on Primary Health and Aging

Committee on Health, Education, Labor, and Pensions

United States Senate

The Honorable Michael B. Enzi

United States Senate

For over a decade, several government, academic, and health 

professional organizations have projected national shortages of health 

care professionals,1 which could result in delays in getting care, or 

patients not receiving needed care.2 However, there is little consensus 

about the nature and extent of any future shortages. In 2008, the Health 

Resources and Services Administration (HRSA)—the agency within the 

Department of Health and Human Services (HHS) responsible for 

monitoring the supply of and demand for health care professionals—

published a physician workforce report that projected a shortfall of 

approximately 49,000 full-time equivalent (FTE) physicians by 2020.3

 

1

We use the term “health care professionals” to encompass allopathic and osteopathic 

physicians, and two groups of nonphysician providers—physician assistants and 

advanced practice registered nurses. These nonphysician providers generally hold 

graduate degrees and may be required to pass national certification exams in order to 

practice medicine. Advanced practice registered nurses can be further divided into nurse 

practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified 

nurse midwives.

2

See, for example, Health Resources and Services Administration, The Physician 

Workforce: Projections and Research into Current Issues Affecting Supply and Demand

(Rockville, Md.: 2008); M. J. Dill and E. S. Salsberg, The Complexities of Physician Supply 

and Demand: Projections through 2025 (Washington, D.C.: 2008); and J. M. Colwill, J. M. 

Cultice, and R. L. Kruse, “Will Generalist Physician Supply Meet Demands of an 

Increasing and Aging Population?” Health Affairs, vol. 27, no. 3 (2008).

3

Health Resources and Services Administration, The Physician Workforce. 

 
 

Page 2 GAO-13-806 Health Care Workforce Projections

That same year, the Association of American Medical Colleges (AAMC) 

projected a gap of 124,000 FTE physicians by 2025.4 In contrast, one 

recently published study found that increases in physician productivity 

due to greater use of technology and incorporation of nonphysician 

providers into team-based care delivery models could offset projected 

shortages of primary care physicians.5 Differences among projections 

may arise partly because accurately determining the supply of and 

demand for health care professionals is a difficult task due to gaps in 

available supply data, especially for nonphysician providers, and a 

number of uncertainties that affect future demand, such as technological 

advances in medicine and changes in disease prevalence. HRSA and 

others attempting to develop new projections must also account for a 

changing health care landscape, due in part to the implementation of the 

Patient Protection and Affordable Care Act (PPACA), as amended by the 

Health Care and Education Reconciliation Act of 2010.

6 The 

Congressional Budget Office has estimated that PPACA will extend 

health insurance coverage to 25 million uninsured individuals beginning in 

2014. PPACA also contains provisions that have the potential to change 

the way health care is delivered, as well as the size and composition of 

the health care workforce. To ensure an adequate health care workforce 

for the nation, the federal government makes a significant investment in 

training programs. For example, total federal spending for workforce 

training was about $14 billion in fiscal year 2012.7

 

4

Dill and Salsberg, The Complexities of Physician Supply and Demand. 

Up-to-date workforce 

estimates are essential information for Congress as it considers policy 

options to address health care workforce issues, including targeted 

funding for training programs.

5

L. V. Green, S. Savin, and Y. Lu, “Primary Care Physician Shortages Could Be 

Eliminated through Use of Teams, Nonphysicians, and Electronic Communication,” Health 

Affairs, vol. 32, no. 1 (2013). In recent work, HRSA has defined primary care physicians to 

be those practicing in family medicine, general practice, general internal medicine, general 

pediatrics, and geriatrics.

6

Pub. L. No. 111-148, 124 Stat. 119 (2010), as amended by Pub. L. No. 111-152, 124 

Stat. 1029 (2010). For purposes of this report, references to PPACA include the 

amendments made by the Health Care and Education Reconciliation Act of 2010. 

7

GAO, Health Care Workforce: Federally Funded Training Programs in Fiscal Year 2012, 

GAO-13-709R (Washington, D.C.: Aug. 15, 2013). This report focused on federal 

programs that provided postsecondary training or education for health professionals or 

supported the costs of such training in fiscal year 2012, including the cost of 

postsecondary graduate medical education residency positions for physicians.
 

Page 3 GAO-13-806 Health Care Workforce Projections

HRSA is the primary federal agency responsible for ensuring and 

increasing access to health care services, particularly for medically 

underserved populations, and for enhancing the capacity of the health 

care workforce. Within HRSA, the Bureau of Health Professions (BHPr) 

has multiple responsibilities related to workforce development, including 

conducting and contracting for studies on the supply of and demand for 

health care professionals. In 2006, we found that HRSA had published 

few national workforce projections despite the importance of such 

assessments to setting health care workforce policy, and we 

recommended that HRSA develop a strategy and establish timeframes to 

more regularly update and publish national workforce projections for the 

health professions.8

Given the wide range of estimates that have been generated about how 

many health care professionals may be needed, you asked us to provide 

information about health care workforce supply and demand projections. 

This report examines the actions HRSA has taken to project the future 

supply of and demand for physicians, physician assistants, and advanced 

practice registered nurses (APRN) since publishing its 2008 physician 

workforce report.

In 2012, HRSA created a timeline, establishing goals 

for producing national projections and a schedule for periodic updates.

To examine actions HRSA has taken to project the future supply of and 

demand for health care professionals, we reviewed relevant sections of 

HRSA’s contracts with research organizations that produce workforce 

models and projections, including statements of work and timelines for 

deliverables. To obtain more detailed information about delivered 

products, we reviewed a published report and a data and methodology 

guide provided by a contractor to HRSA. We also reviewed a workforce 

projection model created under contract and used it to examine projected 

differences between the supply of and demand for physicians by specialty 

in 2025 with and without the addition of nonphysician providers. To 

enhance our understanding of the model’s capabilities and structure, 

HRSA officials provided us with a demonstration and tutorial on the use of 

this model to create workforce projections. Although our reporting 

objective encompassed workforce reports as evidence of actions taken, 

we did not review reports produced by contractors that HRSA had not 

 

8

GAO, Health Professions Education Programs: Action Still Needed to Measure Impact, 

GAO-06-55 (Washington, D.C.: Feb. 28, 2006). 
 

Page 4 GAO-13-806 Health Care Workforce Projections

approved, finalized, and published for public use because it was beyond 

the scope of our review to assess the quality or completeness of such 

interim products. We also reviewed a document summarizing workforce 

data collection and analysis activities conducted by BHPr. We interviewed 

officials from BHPr to clarify and confirm information about the status of 

HRSA’s workforce projections and to obtain information about key 

updates and changes to its models since its 2008 physician workforce 

report, as well as challenges they face in updating projections. We also 

asked officials about policies and procedures for reviewing and publishing 

projection reports to assess the extent to which HRSA monitors its 

progress toward meeting timeline goals. We assessed these policies and 

procedures using criteria from Standards for Internal Control in the 

Federal Government.9

We conducted this performance audit from May 2013 through September 

2013 in accordance with generally accepted government auditing 

standards. Those standards require that we plan and perform the audit to 

obtain sufficient, appropriate evidence to provide a reasonable basis for 

our findings and conclusions based on our audit objectives. We believe 

that the evidence obtained provides a reasonable basis for our findings 

and conclusions based on our audit objectives.

We also compared dates contained in the timeline 

HRSA created in 2012 for publishing updated national health care 

workforce projections with contractual dates for product deliveries, as well 

as with status updates provided by BHPr officials to evaluate HRSA’s

progress. We also interviewed health care workforce researchers and 

representatives from health care professional associations to gain 

additional perspectives on the challenges of creating workforce 

projections.

An adequate supply of health care professionals is necessary to ensure 

access to needed health care services. HRSA estimated that there were 

approximately 780,000 physicians and 261,000 physician assistants and 

 

9

Federal internal control standards state that managers should have access to timely 

information needed to effectively monitor agency progress on meeting its goals and that 

managers should track achievements and performance and compare them to expected 

performance. These standards also state that establishing appropriate control activities, 

such as documenting administrative policies, can help ensure that management’s 

directives are carried out. See GAO, Standards for Internal Control in the Federal 

Government, GAO/AIMD-00-21.3.1 (Washington, D.C.: Nov. 1, 1999).

Background 
 

Page 5 GAO-13-806 Health Care Workforce Projections

advanced practice registered nurses engaged in patient care in 2010.10

Part of maintaining an adequate health care workforce involves projecting 

the future supply of health care professionals and comparing that supply 

to the expected demand for health care services to determine whether 

there will be enough providers to meet the demand. Such projections can 

provide advance warning of shortages or surpluses so that health care 

workforce policies, such as funding for health care training programs, can 

be adjusted accordingly. In its 2008 physician workforce report, HRSA 

noted that due to the long time needed to train physicians and to make 

changes to the medical education infrastructure, policymakers and others 

need to have information on the adequacy of the physician workforce at 

least 10 years in advance.11 We have also previously reported that 

producing supply and demand projections on a regular basis is important 

so that estimates can be updated as circumstances change.12

Health care workforce projections typically measure the supply of health 

care professionals and the demand for services in a base year and 

predict how each will change in the future given expected changes in the 

factors that affect supply and demand. On the supply side, “stock and 

flow” models are commonly used; these models start with the current 

number of health care professionals, add new entrants to the workforce, 

such as students who complete their medical training, and subtract 

providers who are expected to leave the workforce, such as those who 

retire. Factors influencing supply include the capacity of educational 

programs to train new health care professionals, the number of patients 

that health care professionals are able to care for, and attrition rates. On 

the demand side, a utilization-based approach is often used, which 

measures the current utilization of health care services and projects that 

pattern of utilization forward, making adjustments as the population 

receiving services changes over time. Factors affecting demand include 

 

10This estimate includes nurse practitioners, certified registered nurse anesthetists, and 

certified nurse midwives, but not clinical nurse specialists.

11Health Resources and Services Administration, The Physician Workforce, 101. 

12See GAO-06-55. 
 

Page 6 GAO-13-806 Health Care Workforce Projections

economic conditions,13 population growth, and changing population 

demographics such as aging or an increase in insurance coverage.14

At the federal level, HRSA is responsible for monitoring the supply of and 

demand for health care professionals and disseminating workforce data 

and analysis to inform policymakers and the public about workforce 

needs and priorities.15

The PSM is a “stock and flow” model, which projected the future supply of 

physicians by taking the number of physicians from a base year (2000), 

adding new entrants, and subtracting physicians lost through retirement, 

disability, or death. The PSM projected both active supply (the number of 

individual physicians) and the effective supply (the number of FTE 

physicians accounting for the number of hours worked). The number of 

FTEs was determined by the average number of hours worked for 

physicians in each specialty by gender and age group.

To meet this responsibility, HRSA conducts and 

contracts for health care workforce research to document and project 

shortages and to examine trends that influence the supply and distribution 

of health care professionals, as well as the demand for their services. In 

2008, HRSA issued a physician workforce report containing national 

supply and demand projections for physicians through 2020, which was 

based on the agency’s physician workforce models: the Physician Supply 

Model (PSM) and Physician Requirements Model (PRM). Using these 

models, HRSA projected a shortfall of approximately 49,000 FTE 

physicians by 2020.

 

13Research has shown a relationship between economic growth and the demand for 

health care services. See Richard A. Cooper et al., “Economic and Demographic Trends 

Signal an Impending Physician Shortage,” Health Affairs, vol. 21, no. 1 (2002).

14Higher utilization of health care services among individuals with health insurance 

coverage is well documented. For example, see T. C. Buchmueller et al., “The Effect of 

Health Insurance on Medical Care Utilization and Implications for Insurance Expansion: A 

Review of the Literature,” Medical Care Research and Review, vol. 62, no. 1 (2005).

15Every 2 years, the Bureau of Labor Statistics within the Department of Labor also 

produces national 10-year projections of the number of new jobs expected to be created 

for particular occupations. However, these projections are different from HRSA’s because 

they count the number of jobs rather than the number of people and do not assess 

whether there will be a shortage or surplus.
 

Page 7 GAO-13-806 Health Care Workforce Projections

The PRM is a utilization-based model, which projected the demand for 

physicians starting with the utilization of health care services in 2000 by 

age, sex, geographic location, and insurance coverage type (see fig.1). 

The PRM assumed that supply and demand were in equilibrium in 2000, 

that is, that there were enough physicians to meet the demand for health 

care services. The PRM’s baseline projection also assumed that patterns 

of utilization would not change, although HRSA created some alternative 

scenarios showing how utilization might change (and therefore affect 

demand) because of factors such as economic growth. HRSA also 

included a scenario that accounted for the effect of nonphysician 

providers, such as nurse practitioners and physician assistants, who may 

offset the demand for physicians by providing services that otherwise 

would have been provided by physicians.16

 

16HRSA estimated that the number of nonphysician providers would increase by 

60 percent between 2005 and 2020, thereby reducing the demand for physicians in 2020 

by approximately 90,000.

HRSA and others have noted 

that a drawback of the utilization-based approach, which carries forward 

current utilization patterns, is that when calculating the number of 

physicians needed, any current imbalances in the system, such as 

populations that may be underserved, or any overutilization of health care 

services are also carried forward.
 

Page 8 GAO-13-806 Health Care Workforce Projections

Figure 1: Process for Determining Physician Requirements in the Health Resources and Services Administration’s (HRSA) 

2008 Report Based on Its Physician Requirements Model

a

HRSA examined health care utilization patterns by population category using national survey data 

from 1999 to 2001.
 

Page 9 GAO-13-806 Health Care Workforce Projections

HRSA’s 2008 physician workforce report predates PPACA, which was 

enacted in 2010. PPACA contains provisions that have the potential to 

affect both health care workforce supply and demand, which increases 

the uncertainty of health care workforce projections (see table 1). Several 

health care workforce researchers have published estimates of the effects 

of PPACA insurance coverage expansions on workforce supply and 

demand. These studies found varying estimates for the number of 

additional primary care providers required to meet the needs of the newly 

insured population, ranging from 4,300 to 8,000 providers.17 The 

variations in these projections are the result of differences in 

methodologies and assumptions used in modeling. AAMC also increased 

its overall projection of physician shortages for 2025 by 6,200 FTE 

physicians, on the basis of expected increases in health care demand as 

a result of greater rates of insurance coverage under PPACA, among 

other factors.18 PPACA provides for the establishment of new delivery 

models such as accountable care organizations (ACO) and patientcentered medical homes (PCMH).19

 

17A. N. Hofer, J. M. Abraham, and I. Moscovice, “Expansion of Coverage under the 

Patient Protection and Affordable Care Act and Primary Care Utilization,” The Milbank 

Quarterly, vol. 89, no. 1 (2011); Stephen M. Petterson et al., “Projecting U.S. Primary Care 

Physician Workforce Needs: 2010-2025,” Annals of Family Medicine, vol. 10, no. 6 (2012); 

and E. S. Huang and K. Finegold, “Seven Million Americans Live in Areas Where Demand 

for Primary Care May Exceed Supply by More Than 10 Percent,” Health Affairs, vol. 32, 

no. 3 (2013).

ACO models consist of integrated 

groups of providers who coordinate care for a defined patient population 

in an effort to improve quality, reduce costs, and share in any savings. 

The PCMH model is a way of organizing and delivering primary care that 

emphasizes comprehensive, coordinated, accessible, and quality care 

built on strong patient-provider relationships. Such models also 

encourage shifting care provision to nonphysician providers, potentially 

decreasing the need for additional physicians. Some researchers have 

stated that they expect new delivery models, such as ACOs, will have a 

18Dill and Salsberg, The Complexities of Physician Supply and Demand, 503; and Center 

for Workforce Studies, Association of American Medical Colleges, The Impact of Health 

Care Reform on the Future Supply and Demand for Physicians Updated Projections 

through 2025 (Washington, D.C.:, 2010). Other factors affecting physician demand cited in 

AAMC’s updated projections include an adjustment made for the increasing incidence of 

obesity in the United States.

19The Centers for Medicare & Medicaid Services defines ACOs as groups of doctors, 

hospitals, and other health care providers who come together voluntarily to give 

coordinated, high-quality care to their Medicare patients, enabling them to share in 

savings they achieve for the Medicare program.
 

Page 10 GAO-13-806 Health Care Workforce Projections

significant and lasting effect on the broader health care marketplace, 

though research shows conflicting results as to how these new delivery 

models will affect the supply of and demand for health care 

professionals.20

Table 1: Selected Program Areas Addressed by the Patient Protection and Affordable Care Act (PPACA) and Their Potential 

Health Care Workforce Effects

Program area description Potential workforce effect

Insurance coverage: Expands public and

private health insurance coverage

May increase the number of nonelderly Americans with health insurance by 

approximately 25 milliona

Workforce training: Provides for targeted 

funding for health professional training

thereby increasing the projected utilization of health services 

and the demand for providers.

May change the supply, composition, and geographic distribution of the health care 

workforce and address projected shortages in primary care and certain specialty 

providers.

b

Provider payment: Temporarily increases 

Medicare and Medicaid provider payment 

rates for primary care services

Higher payments may increase the supply of primary care providers willing to accept and 

treat Medicare and Medicaid patients.

Delivery system innovation: Supports and 

tests new models for improving health care 

delivery

Fosters new and potentially more efficient models for care organization, delivery, and 

payment, which may affect utilization of health care services and therefore the demand 

for certain provider types.

Source: GAO

c

a

Congressional Budget Office, Updated Budget Projections: Fiscal Years 2013 to 2023, Pub. 

No. 4722 (Washington, D.C.: May 2013). The Congressional Budget Office estimates that 25 million 

nonelderly uninsured individuals will obtain insurance by 2023.

b

For example, PPACA authorized approximately $4 billion in funding for fiscal years 2010 through 

2015 for the National Health Service Corps program, which provides scholarships and student loan 

repayments to health professionals who agree to work in designated underserved areas. Pub. L. 

No. 111-148, § 5207, 124 Stat. 119, 612 (codified at 42 U.S.C. § 254q). In fiscal year 2012, the 

National Health Service Corps program made almost 4,600 loan repayment and scholarship awards.

c

 

20For example, studies show conflicting results as to whether adoption of new health care 

delivery models will allow physicians to care for larger numbers of patients because the 

models allow for delegation to nonphysician providers, or whether these models will 

require additional physicians and other nonphysician providers because additional 

services such as care coordination and patient education will be offered. For research 

showing that new delivery models may allow providers to care for larger numbers of 

patients, see L. V. Green, S. Savin, and Y. Lu, “Primary Care Physician Shortages Could 

Be Eliminated.” For research showing that providers implementing new delivery models 

have reduced the average number of patients they care for to improve care coordination 

and quality, see R. J. Reid et al., “The Group Health Medical Home at Year Two: Cost 

Savings, Higher Patient Satisfaction, and Less Burnout for Providers,” Health Affairs, 

vol. 29, no. 5 (2010).

For example, PPACA authorizes the testing of patient-centered medical homes that aim to better 

coordinate care and therefore reduce health care utilization. Pub. L. No 111-148, §§ 3021, 10306, 

124 Stat. 119, 389, 939 (codified at 42 U.S.C. § 1315a). Such models have the potential to shift 
 

Page 11 GAO-13-806 Health Care Workforce Projections

primary care provision to nonphysician providers, which may decrease the need for additional primary 

care physicians.

PPACA also mandated the establishment of the National Health Care 

Workforce Commission21 and required HHS to establish the National 

Center for Health Workforce Analysis (NCHWA)22 to collect and analyze 

data on the health care workforce and evaluate workforce adequacy.23

The National Health Care Workforce Commission was charged with 

conducting analyses of health care supply and demand and submitting 

annual reports to Congress that included recommendations. However, 

this commission has not received appropriations and therefore has not 

met since it was appointed. In 2010, HRSA established NCHWA within its 

Bureau of Health Professions. NCHWA is responsible for developing and 

disseminating accurate and timely data and research on the health care 

workforce, among other things. In 2012, NCHWA produced a timeline for 

updating HRSA’s workforce projections, as we recommended.24

 

21Pub. L. No. 111-148, §§ 5101, 10501, 124 Stat. 119, 592, 993 (codified at 42 U.S.C. 

§ 294q).

22Pub. L. No. 111-148, § 5103(a), 124 Stat. 119, 603 (codified at 42 U.S.C. § 294n(b)).

23NCHWA was charged with developing information describing and analyzing the health 

care workforce and workforce-related issues and collecting, compiling, and analyzing data 

on health care professionals, among other things. PPACA authorized NCHWA to enter 

into contracts with relevant professional and educational organizations or societies to 

carry out these activities.

24In 2006, we recommended that HRSA develop a strategy and establish time frames to 

more regularly update and publish national workforce projections for the health 

professions. See GAO-06-55. 
 

Page 12 GAO-13-806 Health Care Workforce Projections

Since its last published report on physician supply and demand in 2008, 

HRSA has initiated work to produce new workforce models and reports, 

but has not published any new reports containing national workforce 

projections. Specifically, HRSA has missed one of its publication goals for 

new workforce projections and has created a revised timeline that 

postpones future publications. Given that HRSA’s 2008 report was based 

on 2000 data, the most recent projections available from HRSA to 

Congress, researchers, and the general public to inform health care 

workforce policy decisions are based on data that are more than a 

decade old.25 From 2008 to 2012, HRSA awarded five contracts to three 

research organizations to update or create new workforce projection 

models, generate new national workforce projections, and produce 

reports. (See table 2 for a summary of the contracts and their status.) As 

of July 2013, HRSA had received three reports resulting from these 

contracts, and two more reports were under development. Contractor A 

delivered the first report, which includes projections for the primary care 

workforce to 2020, in July 2010, but HRSA was still reviewing and 

revising the draft as of July 2013. HRSA officials said that this primary 

care report has required extensive consultation with other HHS 

components to ensure that the methods used were consistent with other 

ongoing workforce-related work within the department. In addition, 

officials said that significant revisions were required to incorporate the 

effects of PPACA. Contractor B delivered the second report, which 

updated HRSA’s 2008 physician workforce projections using more recent 

data, in February 2011. However, according to HRSA officials, the agency 

decided not to publish this report because it did not incorporate 

nonphysician providers, which they have since determined should be 

accounted for when assessing the adequacy of the health care

workforce.26

 

25For example, a Senate bill was introduced in March 2013 that would distribute physician 

training slots to medical specialties that were projected to experience shortages in HRSA’s 

2008 report. Resident Physician Shortage Reduction Act of 2013, S. 577, 113th Cong. 

(2013).

However, officials also said that research conducted under 

this contract regarding the health care workforce effects of PPACA was 

incorporated into HRSA’s later projection models. The third report, the 

clinician specialty report, which projects the supply of and demand for 

26HRSA did not include nonphysician providers in the scope of work for this contract 

because, according to officials, the purpose of the contract was to update its physician 

projection models.

HRSA Has Taken 

Some Actions to 

Update National 

Projections, but Has 

Failed to Publish New 

Reports Since 2008
 

Page 13 GAO-13-806 Health Care Workforce Projections

health care professionals by specialty through 2025, was delivered in 

November 2012 and is still under HRSA’s review.

Table 2: Summary of the Health Resources and Services Administration’s (HRSA) Contracts with Research Organizations 

Since 2008 to Create Health Care Workforce Projections

Contractor

Funds 

obligated Topic and key tasks 

Performance 

period start date

Contractor report 

due to HRSA

Status 

(as of July 2013)

Contractor A $299,997 a Primary care: Produce a report on 

primary care workforce supply and 

demand projections to 2020 at the 

national, state, and substate 

levels.

September 2008 July 2010 Under review at 

HRSA

Contractor B $376,336 Physician workforce: Update the 

physician supply and requirements 

models to use a baseline year of 

2008, extend projections to 2030, 

and produce a report; conduct 

research on effects of the Patient 

Protection and Affordable Care Act 

(PPACA). 

August 2009 February 2011 Completed, but 

officials said HRSA 

does not intend to 

publish

Contractor B

b

$372,811 Clinician specialty: Develop new 

clinician specialty workforce 

models that integrate nonphysician 

providersc

September 2011

and can model 

individual specialties, and produce

a report with national projections to 

2025.

November 2012 Under review at 

HRSA

Contractor C $399,783 Nursing workforce: Develop new 

nursing microsimulationd supply 

and demand models,

e

September 2012

and 

produce a report with supply and 

demand projections to 2030 at the 

state and national levels.

September 2013 Under development

by contractor

Contractor C $499,848 f Cross-occupations: Develop new 

microsimulation cross-occupations 

model using publicly available data 

that can make supply and demand 

projections across occupations 

and produce a report.

September 2012 September 2013 Under development 

by contractor

Source: GAO analysis of HRSA information. 

a

This contract also included work to support the Council on Graduate Medical Education, one of 

HRSA’s advisory committees that provides assessments of physician workforce trends, training 

issues, and financing policies.

b

Officials said that research conducted under this contract regarding the effects of PPACA was 

incorporated into later models.

c

HRSA includes three types of advanced practice registered nurses (APRN) in its clinician specialty 

models: nurse practitioners, certified registered nurse anesthetists, and certified nurse-midwives. The 

fourth type of APRN—clinical nurse specialists—was not included, partly due to the difficulty of 

getting consistent data on the numbers for this group given varying state licensure requirements.
 

Page 14 GAO-13-806 Health Care Workforce Projections

d

Microsimulation models are statistical models that use micro data—data at the micro level such as 

individuals or households—to capture behavioral responses of these micro units to changes in 

economic and social policies. According to HRSA, the use of microsimulation will allow the inclusion 

of a larger number of predictive variables and will provide the ability to make projections at the state 

and local levels.

e

According to HRSA, this model will include APRNs.

f

HRSA has missed one of its timeline goals for finalizing its review and 

publishing new reports containing national projections and has created a 

new timeline that postpones publication dates for this and two other 

health care workforce reports. Although HRSA’s original timeline stated 

that the clinician specialty report would be published in December 2012, 

HRSA’s revised timeline states that this report is expected to be 

published in the summer of 2014.

This contract also includes three option years that, if exercised, would add about $1 million to the 

total obligated amount for additional health care modeling work.

27

Table 3: Health Resources and Services Administration’s (HRSA) National Center 

for Health Workforce Analysis Original and Revised Timelines for Publishing 

Updated Workforce Supply and Demand Projections

The revised timeline also included 

new publication dates for HRSA’s report on the primary care workforce 

and for reports based on its new microsimulation models. (Table 3 shows 

HRSA’s original and revised timelines for publication.)

Report Original goal for publication Revised goal for publication

Primary care No goal date Fall 2013

Clinician specialty December 2012 Summer 2014

Nursing workforce September 2013 Fall 2014

Cross-occupations 2013 2014

Source: GAO review of HRSA information.

HRSA attributed the delay in publishing the clinician specialty report to 

data challenges and modeling limitations. For example, HRSA officials 

cited limited research and data on the effects of new health care delivery 

models being funded and tested in response to PPACA.28

 

27HRSA revised its timeline in July 2013. See 

http://bhpr.hrsa.gov/healthworkforce/workforceprojections.html. 

HRSA officials 

told us that new models such as ACOs and PCMHs have not yet been 

28HRSA officials also cited limited data on how other changes in health care delivery, such 

as the expanding use of health information technology, will affect workforce supply and 

demand. 
 

Page 15 GAO-13-806 Health Care Workforce Projections

studied adequately to know whether they will increase or decrease the 

demand for health care professionals. It may be several years before 

relevant data are available. According to a health care workforce 

researcher we interviewed, there is going to be an inevitable lag in 

obtaining data given that some delivery system models, such as ACOs,

are still being set up, and time will be needed to collect and analyze data 

and publish any findings. In addition, other researchers have pointed out 

that workforce-relevant data are not being systematically collected from 

new models being supported and tested in response to PPACA. HRSA 

officials also have cited challenges due to limited research on 

nonphysician providers. For example, more research is needed to 

determine how much nonphysician providers offset the demand for 

physicians across different specialties.29 In our review of HRSA’s clinician 

specialty models, we observed that for some specialties, the addition of 

nonphysician providers has the potential to turn projected shortages into 

surpluses.30

HRSA officials said that the agency does not have a standard written 

work plan or set of procedures for accomplishing the tasks necessary to 

prepare a report for publication after final reports are delivered from 

Another challenge HRSA officials said they need to address 

stems from an inherent limitation of utilization-based models, namely, that 

they project forward the utilization patterns of the past and therefore do 

not adequately account for rapid changes in the health care system. 

HRSA officials said that this modeling limitation has caused surpluses 

and shortages that do not reflect anticipated workforce trends and require 

time to analyze. For example, officials explained that when a provider 

specialty is in shortage, utilization is by definition low. If investments are 

made to increase the supply of the specialty in shortage, then the model 

carries forward the past low utilization and incorporates increased 

provider supply, which consequently projects a surplus for the future 

because there will be more providers than were utilized in the past.

 

29HRSA uses a “productivity rate” of 0.75 in its clinician specialty models, which means 

that a nonphysician provider is assumed to provide three-quarters of the care to patients 

provided by a physician. However, it is not known whether a nonphysician provider who 

works in cardiology supplies the same percentage of patient care as a nonphysician 

provider working in primary care. HRSA has the capability to adjust this rate for each 

specialty, but in the absence of specific research on how the rate should be adjusted by 

specialty, HRSA is using 0.75 for all specialties.

30Using HRSA’s clinician specialty models, we examined projected differences between 

the supply of and demand for physicians by specialty in 2025 with and without the addition 

of nonphysician providers. 
 

Page 16 GAO-13-806 Health Care Workforce Projections

contractors.31 Officials said that although there are general policies that 

guide review, the specific steps of the review process and which internal 

and external officials participate are determined on a case-by-case 

basis.32 In addition, officials said that it is common for milestone dates to 

change depending on the complexity of the issues raised during review. 

According to HRSA officials, the dates included in their timeline were 

based solely on when they expected to receive models and reports from 

contractors and did not account for the continued analytical work involved 

in reviewing delivered products. For example, according to HRSA 

officials, the original 2013 goal dates for publishing reports based on the 

new microsimulation models had to be postponed until 2014 because 

they will require additional time to review after they are received. Without 

standard procedures, agency officials may not be able to accurately 

predict how long products will take to review or to monitor their progress 

through the review process to ensure they are completed in a timely 

manner.33 However, HRSA officials have stated that once the 

microsimulation models are completed, these models will offer the ability 

to more easily update projections as new data become available and 

should result in more routine and frequent reporting.

The federal government has made significant investments in health care 

professional training programs to help ensure that there is a sufficient 

supply of health care professionals to meet the nation’s health care 

needs. Health care workforce projections play a critical role in providing 

information on future shortages or surpluses of health care professionals 

so that policies can be adjusted, including targeting health care training 

funds to the areas of greatest need. We recommended in 2006 that 

HRSA, as the federal agency designated to monitor the supply of and 

demand for health care professionals, develop a strategy and establish 

 

31Federal internal control standards state that management is responsible for 

developing the detailed policies, procedures, and practices to fit the agency’s 

operations and to ensure that they are built into and an integral part of operations. 

See GAO/AIMD-00-21.3.1.

32According to HRSA, officials consider the content of the product and the expertise 

required to review it when deciding who participates in the review process.

33Federal internal control standards state that managers should have access to timely 

information needed to effectively monitor agency progress on meeting its goals and that 

managers should track achievements and performance and compare them to expected 

performance. See GAO/AIMD-00-21.3.1.

Conclusions 
 

Page 17 GAO-13-806 Health Care Workforce Projections

time frames to more regularly update and publish national workforce 

projections for the health professions. While HRSA created a timeline for 

publishing new projection reports in 2012, the agency has since revised 

its timeline to postpone publication of two other health care workforce 

reports after failing to meet its December 2012 publication goal for a 

clinician specialty report projecting the supply of and demand for health 

care professionals through 2025. Other reports that have been delivered 

by contractors since HRSA published its last report in 2008 have either 

been set aside or are still being reviewed. In the case of the primary care 

workforce report containing projections to 2020, review has been ongoing 

for 3 years. If this report were published in 2013, it would project only 

7 years into the future. HRSA itself has stated that physician workforce 

projections should be completed at least 10 years in advance to provide 

enough time for policy interventions to influence the size and composition 

of the workforce. In the absence of published projections, policymakers 

are denied the opportunity to use timely information from HRSA to inform 

their decisions on where to direct billions of dollars in training funds. It is 

also important to update projections on a regular basis so that changing 

circumstances, such as the enactment of PPACA or the growth in 

nonphysician providers, can be incorporated. Currently, the most recent 

projections available from HRSA are based on patterns of utilization and 

care delivery in 2000, predating PPACA by a decade. HRSA is now 

making larger financial investments in new workforce projection models, 

but in the absence of standard written processes specifying how the 

reports resulting from these models will be reviewed, HRSA may be 

hindered in its ability to monitor the development of these reports and 

ensure that they are published in keeping with its revised timeline.

We recommend that the Administrator of HRSA take the following three 

actions:

Expedite the review of the report containing national projections to 

2020 for the primary care workforce to ensure it is published in the fall 

of 2013 in accordance with HRSA’s revised timeline.

Create standard written procedures for completing the tasks 

necessary to review and publish workforce projection reports 

delivered from contractors; such procedures may include a list of 

necessary review steps, estimates of how long each step should take 

to complete, and designated internal and external reviewers.

Recommendations 
 

Page 18 GAO-13-806 Health Care Workforce Projections

Develop tools for monitoring the progress of projection reports through 

the review process to ensure that HRSA’s timeline goals for 

publication are met.

We provided a draft of this report to HHS for review. HHS’s comments are 

reprinted in appendix I. HHS also provided technical comments, which we 

incorporated as appropriate.

In its comments, HHS agreed with our recommendations and described 

actions that the department is taking to implement them. In response to 

our first recommendation to expedite the review and publication of a 

report containing primary care workforce projections, HHS said that it 

expects to release the report on schedule in the fall of 2013. Regarding 

our second recommendation to develop standard written procedures for 

report review, HHS said that HRSA has developed a framework for report 

development based on project management principles that is being made 

available electronically to all HRSA employees. According to HHS, this 

framework facilitates planning and provides guidance throughout the 

report development process. Concerning our third recommendation to 

develop tools for monitoring the progress of reports through the review 

process, HHS said that HRSA has created a computer-based tool 

capable of generating estimated time ranges for completing each step in 

the report development and review process, which it anticipates will allow 

for better oversight of report timelines. In addition to these agencywide 

efforts, HHS said that BHPr is in the process of developing a review 

process specifically for proposed workforce studies and contracts that will 

emphasize more comprehensive review in the early stages of 

development with the aim of reducing the time needed for final report 

review.

In addition to addressing our recommendations, HHS commented that our 

draft report did not discuss a number of other workforce-related activities 

undertaken by NCHWA, such as data collection efforts and the production 

of reports that do not include national projections. For example, in 2012 

NCHWA fielded a survey to collect nationally representative data on 

nurse practitioners. While we agree with HHS that such activities are 

important, they are not a substitute for regularly producing updated 

national projections. We did not include information in this report on other 

HRSA reports not containing national projections, or HRSA's data 

collection efforts, because the scope of our review was limited to national 

projections of the supply of and demand for physicians, physician 

assistants, and APRNs.

Agency Comments
 

Page 19 GAO-13-806 Health Care Workforce Projections

As arranged with your office, unless you publicly announce the contents 

of this report earlier, we plan no further distribution until 30 days after its 

issuance date. At that time, we will send copies of this report to the 

Administrator of HRSA and other interested parties. In addition, the report 

will be available at no charge on the GAO website at http://www.gao.gov. 

If you or your staff members have any questions, please contact me at 

(202) 512-7114 or kingk@gao.gov. Contact points for our Offices of 

Congressional Relations and Public Affairs may be found on the last page 

of this report. Major contributors to this report are listed in appendix II.

Kathleen M. King

Director, Health Care
Appendix I: Comments from the Department of 

Health and Human Services 

Page 20 GAO-13-806 Health Care Workforce Projections

Appendix I: Comments from the Department 

of Health and Human Services
Appendix I: Comments from the Department of 

Health and Human Services

Page 21 GAO-13-806 Health Care Workforce Projections
Appendix I: Comments from the Department of 

Health and Human Services

Page 22 GAO-13-806 Health Care Workforce Projections
Appendix II: GAO Contact and Staff 

Acknowledgments

Page 23 GAO-13-806 Health Care Workforce Projections

Kathleen King, (202) 512-7114 or kingk@gao.gov

In addition to the contact named above, Martin T. Gahart, Assistant 

Director; Hannah Locke; Elise Pressma; and Jennifer Whitworth made 

key contributions to this report.

Appendix II: GAO Contact and Staff 

Acknowledgments 

GAO Contact

Staff 

Acknowledgments 

(291100)
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